Teen Pregnancy




T

he
subject of teen pregnancy is frequently covered in major newspapers
and magazines. The impression made by dramatic headlines is one
of irresponsible, sex- crazed young people engaging in promiscuous,
unprotected sex leading to an “epidemic” of teen pregnancies.
These articles, as well as current government, insurance industry,
and educational policies related to teen pregnancy, often ignore
sound science and public health and are marred by misinformation,
religious zealotry, simplistic and unworkable solutions, and prejudice
and “victim blaming.” 



Teen
pregnancy rates are decreasing

. Greater than 50 percent of high
school-age adolescents are sexually active; average age at first
intercourse is 17 for girls and 16 for boys.  Current birth
rates of girls age 15 to 19 (49 births per thousand females) have
gradually decreased since 1960. Over the last ten years, the percentage
of high school students who have had multiple partners decreased
by 24 percent. Up to two-thirds of adolescents use condoms, three
times as many as did so in the 1970s. 



Teen
pregnancy is linked to poverty

. Despite the increased use of
birth control, the U.S. has rates of teen pregnancy, which are three
to ten times higher than those among the industrialized nations
of Western Europe. U.S. teen poverty rates are higher by a similar
magnitude. Six out of seven U.S. teen births are to the 40 percent
of girls living at or below the poverty level, and more teenage
girls are dropping below this level due to Clinton/Bush policies
aimed at “reforming” (deforming?) welfare. 



Adult
males usually impregnate teenage girls

. The role of adult males
in teen pregnancy is under-recognized.  In the most comprehensive
study to date of males directly responsible for teen pregnancies,
conducted in California in 1993, 71 percent of teen pregnancies
(for whom a father was reported) were fathered by adult men with
an average age of 22.6 years, or 5 years older than the mothers.
More births were fathered by men over 25 than by boys under 18.
Sexually transmitted disease and acquired immunodeficiency syndrome
rates among teenage girls are two to four times higher than among
age-matched teenage boys; instead, teenage girls’ rates are
closer to adult male rates. Statutory rape, in which adult perpetrators
or boyfriends have sexual intercourse with underage girls, is infrequently
reported by providers. States are evenly split on whether or not
mandated reporting is required.



Lack
of access to contraception facilitates teen pregnancy.

Only
8 percent of U.S. high schools provide condoms, despite the fact
that promotion and distribution of condoms does not increase teen
sexual activity. Access to contraception of all types is particularly
burdensome for rural teens. Recently, legislation that would prohibit
prescribed contraceptives for adolescents without parental involvement
was introduced in ten states and the U.S. Congress. A survey of
girls younger than 18 seeking services at Planned Parenthood found
that mandatory notification for prescribed contraceptives would
impede girls’ use of sexual health care services, potentially
increasing teen pregnancies and the spread of STDs. 


Across
the U.S., many health plans fail to cover all contraceptive methods,
even though all methods are more effective and less costly than
no method. Many fewer plans cover abortion than cover sterilization,
leaving poor women in the unenviable position of having to choose
sterilization if they lack the resources for adequate contraception
or for an abortion (which may become necessary even when accepted
contraceptive methods are used as directed). On a positive note,
the U.S. House of Representatives recently voted to reinstate the
contraceptive coverage for federal employees that President Bush
omitted in his 2002 budget proposal. 


The
availability of emergency contraception should help further decrease
teen pregnancy rates, especially if it becomes available over-the-counter,
as the American Medical Association and the American College of
Obstetrics and Gynecology have recommended. Even so, some Catholic
hospitals prohibit discussion of emergency contraception, even with
rape victims. 



Sex
education: the good, the bad, and the ineffective

. The vast
majority of sex education programs in the U.S. do not affect teenage
behavior in any substantial way. They neither promote more sexual
activity, nor do they significantly reduce unprotected sex.  The
few programs that do work give teenagers a clear and narrow message—delay
having sex, but if you have sex, always use a condom. Good programs
also teach teens how to resist peer pressure. Unfortunately, “Welfare
Reform” legislation allocated states $50 million over 5 years
to teach abstinence, rather than to provide contraceptives. In 1988,
only 2 percent of U.S. school districts relied solely on abstinence-only
sex education programs; by 1999, 23 percent did. 



Abortion
is common yet increasingly difficult to obtain

. Contrary to
occasional media depictions of teens as the main recipients of abortions,
48 percent of those having the procedure are over age 25; 20 percent
are married; 56 percent have children.  By age 45, the average
female will have had 1.4 unintended pregnancies; 43 percent will
have had an induced abortion. Fifty-eight percent of women with
unintended pregnancies get pregnant while using birth control. This
is not surprising, given one year contraceptive failure rates ranging
from 2 to 3 percent for IUDs, to 7 percent for contraceptive pills,
to 21 percent for periodic abstinence.  Even so, between 1990
and 2000, the number of annual abortions dropped 18 percent, from
1.6 million to 1.3 million. 


Since
the 1973

Roe v. Wade

decision legalizing abortion, various
barriers have been erected in the path of those seeking to obtain
one.  The Hyde Amendment of 1977 cut off Medicaid funding for
nearly all abortions.  Before former President Clinton took
office, discussion of abortion in federally funded health clinics
was prohibited. Thirty-nine states have parental notification laws,
which have led to a rise in late trimester abortions and to increased
numbers of abortions in neighboring states without such laws. 


Recently,
the Bush administration drafted a policy that would let states define
unborn children as persons eligible for medical coverage. The current
Administration has also introduced bills to increase the $3 million
per year already spent on so-called “Crisis Pregnancy Centers,”
in which pregnant women are given non-factual information regarding
abortion, refused information about contraception, shown an ultrasound
of their fetus, and watch a slide show depicting bloody aborted
fetuses in which it is claimed that abortion is a leading cause
of sterility, deformed children and death. In fact, it is 30 times
more dangerous to carry a fetus to term than to undergo a legal
abortion. The availability of mifepristone (RU-486) for medical
pregnancy termination has the potential to improve women’s
access to safe abortion. 


Abortions
cost approximately $350; most patients pay out of pocket. Only one
out of three patients has insurance coverage, and only one out of
three insurance companies cover the procedure after the deductible
is met. Thirty- four states provide no Medicaid funding for abortion;
of the 16 that provide coverage, most make it available only in
cases of fetal abnormality, rape, or when the pregnant woman’s
life is endangered or health at risk because of the pregnancy (see
“Georgia’s Abortion Bill,”

Z Magazine

, January
2003). Often patients are reluctant to file claims due to confidentiality
concerns. 


Other
obstacles to abortion include bans on specific methods, mandated
waiting periods, parental and spousal notification laws, regulation
of abortion facility locations, zoning ordinances designed to keep
abortion clinics from being built in certain areas, and TRAP (Targeted
Regulation of Abortion Providers) laws. 


Bills
already approved by the House of Representatives, and headed for
the Republican-majority Senate, include: the Unborn Victims of Violence
Act, which gives legal status to a fetus hurt or killed during the
commission of a federal crime; the Child Custody Protection Act,
which makes it a crime in some cases to transport a minor across
state lines for an abortion; and the Abortion Non-Discrimination
Act, forbidding state and local government actions against hospitals
or health care workers who refuse to participate in abortions. Three
recent appointments to the Food and Drug Administration’s Reproductive
Health Drugs Advisory Committee, Drs. David Hager, Susan Crockett
and Joseph Stanford, are avowed foes of abortion rights. Obstetrician-gynecologist
Hager, who has advocated Scripture reading and prayer for premenstrual
syndrome, reportedly refuses to provide contraceptives to unmarried
woman. 


It
is time to approach teen pregnancy with rational public health policies,
which acknowledge the myriad social injustices facilitating teen
pregnancy, employ methods known to reduce unwanted pregnancies,
and aim to improve the health and welfare of teenage mothers and
their children. Suggested policies  could include: 


  • Early, ongoing,
    and accurate sex education 

  • Enhanced access
    to reproductive health services, through the enactment of universal
    coverage and by building, staffing, and providing protection for
    the staff of reproductive health clinics 

  • More comprehensive
    training of physicians, especially obstetrician-gynecologists,
    in contraception and abortion 

  • Overturning
    parental notification laws; increasing federal funding for family
    planning 

  • Providing financial
    and other incentives to support young women who wish to continue
    their education and to improve the lives of those living in poverty
    (for example, via enactment of living wage statutes and by bringing
    women’s salaries into line with those of men having equivalent
    training and job requirements). 


Success
in these endeavors will require the concerted efforts of medical
educators, health professionals, teachers, employers, non- governmental
organizations, concerned citizens, and our elected representatives.







Martin
Donohoe is a senior scholar at the Center for Ethics in Health Care,
and Assistant Clinical Professor of Medicine at Oregon Health and
Science University.